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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT c} $.3 (P,&-. 93 to <br />(Std&t Address) (City) <br />HEREBY AUTHORIZE )114X_ &L1nnn4Ae&& <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />(If A icable <br />/ <br />(P e Print) <br />13 0 <br />(Owner/ perator Signature) <br />%(Title) <br />(Date) <br />ADDRESS: _ %S, C 1 <br />(Mailing Address) <br />9 0 <br />(City) (State) (Zip Code) <br />PHONE: (a o a ) q Igo 9 ® T 7 7 — .3lo <br />EH 23 046 (Revised 9/11/96) Page 9 <br />